Mesenchymal Stem Cells Engineered to Produce Brain-Derived ... HDSA Natio… · • CIRM’s...

Mesenchymal Stem Cells Engineered to Produce Brain-Derived Neurotrophic Factor as a Potential

Treatment for Huntington’s Disease

Vicki Wheelock, MD Director, HDSA Center of Excellence at UC Davis

HDSA National Convention Dallas, TX - June 27, 2015

Overview

Stem cells and genetic engineering

Preclinical studies in transgenic HD mouse models in support of our proposed trial

Manufacturing of MSC/BDNF in readiness for regulatory approval for a first-in-human Phase I trial

PRE-CELL: lead-in observational study

HD-CELL: Proposed Phase I open-label safety and tolerability trial

MSC/BDNF for HD

Abbreviations used in this talk

MSC = mesenchymal stem cells

BDNF = brain-derived neurotrophic factor

MSC/BDN = MSCs engineered to express BDNF

YAC128, R6/2= mouse models of HD used for research

FDA = US Food and Drug Administration

IND = Investigational New Drug license

DSMB = Data and Safety Monitoring Board

PRE-CELL = A pre-cellular therapy observational study in early-stage HD

HOPE = what we need!

MSC/BDNF for HD

August 9, 2001

Crawford, Texas

MSC/BDNF for HD

President Bush’s prime-time address to announce federal restrictions on embryonic stem cell research

Federal funding was restricted to 60 embryonic stem cell lines (only approx. 20 were suitable for research)

MSC/BDNF for HD

MSC/BDNF for HD

• Proposition 71 was passed as a ballot initiative • Official Results

Yes votes: 7,018,059 [51.9%] No votes: 4,867,090 [40.9%]

• Prop 71 authorized the sale of $3 billion of state bonds to create the California Institute for Regenerative Medicine (CIRM)

• CIRM’s mission is to finance stem cell research through the construction of research facilities and the funding of research

• CIRM is the largest source of funding for embryonic and pluripotent stem cell research in the world.

California - November 2, 2004

MSC/BDNF for HD

2010 – CIRM Spotlight on HD

MSC/BDNF for HD

Types of Stem Cells

MSC/BDNF for HD

Adult Stem Cells Pluripotent Cells

Blood forming (hematopoietic) Embryonic

Mesenchymal (supporting cells) Induced pluripotent stem cells

Nolta Lab, 1987-present Book published - 2006

MSC/BDNF for HD

MSCs can be engineered to secrete copious amounts

of factors for delivery to other cells and

tissues in the body

MSC/BDNF for HD

BDNF: a lead candidate for HD treatment

Survival and function of striatal neurons is dependent on brain-derived neurotrophic factor (BDNF). Mutant huntingtin protein blocks production of BDNF at the RNA level and reduces axonal transport from the cortical cells to the striatum. Levels of this trophic factor are significantly reduced in the brains of HD patients. Dey et al showed that MSCs engineered to over-express BDNF slowed the progression of HD in a transgenic mouse model. BDNF delivery triggers the recruitment of new neurons in HD transgenic mouse model.

MSC/BDNF for HD

C. Zuccato, M. Valenza, E. Cattaneo, Physiol Rev 2010;90:, 905 Dey ND et al. Behav Brain Res 2010;193-2000

Benraiss A. Cell Stem Cell 2013;787-799

MSCs: our candidate for delivery of BDNF

MSCs secrete neurotrophic factors, reduce inflammation, reduce programmed cell death, enhance connections between neurons and reduce cell toxicity

MSCs can be readily engineered using viral vectors to robustly deliver growth factors

Vectors do not integrate into host cells

MSCs do not require immunosuppression

• Unlike embryonic or pluripotent stem cells, MSCs have a strong safety profile in clinical trials

• 43 published, peer reviewed proof of concept studies have demonstrated efficacy for MSC, BDNF, or MSC/BDNF in HD mouse models (Reviewed in Deng et al, in press 2015)

MSC/BDNF for HD

July 26, 2012 MSC/BDNF grant is approved by CIRM!

MSC/BDNF for HD

Mesenchymal Stem Cells Engineered to produce BDNF as a treatment for HD CIRM Grant DR2A-05415

Objectives:

To obtain FDA approval and to successfully complete a 2-year Phase I trial of cellular therapy in patients with early-stage Huntington’s disease (HD).

Our cell/gene therapy development candidate is safety modified donor-derived human mesenchymal stem cells engineered to secrete brain-derived neurotrophic factor (MSC/BDNF), as a neuroprotective strategy to rescue brain cells that are degenerating in patients with Huntington’s disease.

MSC/BDNF for HD

Project Plan: MSC/BDNF for HD CIRM Grant DR2A-05415

MSC/BDNF for HD

(on-going)

Pre- clinical

Clinical

PRE-CELL: Years 1&2 HD-CELL: Years 3&4

MSC/BDNF for HD

MSCs divide to make more cells. We expand them to larger numbers following Standard Operating Procedures and add extra DNA to make BDNF.

BDNF production by the engineered MSCs

MSC/BDNF for HD

0.0

5000.0

10000.0

15000.0

20000.0

25000.0

WT MOI 2 MOI 5 MOI 10 MOI 20

BDN

F (p

g/20

0k c

ells

/24h

rs)

BDNF Production: hMSC pCCLc-MNDU3-BDNF-WPRE

BDNF Production: Human MSCs were transduced with the lentiviral vector pCCLc-MNDU3-BDNF-WPRE at the indicated Multiplicity of infection (MOI). Increasing the MOI increases the amount of BDNF produced.

MSC/BDNF for HD

No differences in appearance were detected between gene-modified cells (MSC/BDNF) and unmodified MSCs

MSC/BDNF Characterization

Non-transduced BDNF-transduced

MSC/BDNF for HD

NSC/BDNF Characterization: Stable Karyotype

HD and JHD Mouse Model Studies

MSC/BDNF for HD

MSC/BDNF for HD

We used the YAC128 and R6/2 (120) strains of mice as models of HD and Juvenile HD – The YAC128 mouse has late onset, mild symptoms, and striatal atrophy – The R6/2 (120) mouse has early onset and seizures, and very early death

(approx. 90 days) Mice were immune suppressed to permit survival of human cells Mice were transplanted with 500,000 human MSC or MSC/BDNF in the

brain

Mouse models of Huntington’s disease

In Vivo Retention of Human MSC

MSC/BDNF for HD

A combination of FK506 and rapamycin delivered via subcutaneous osmotic mini-pumps increased luciferase-MSC retention in the striata to levels similar to that observed in immune-deficient mice

Pre-clinical Summary: YAC128 model

Mice treated with MSC/BDNF had significantly greater exploratory behaviors in open field testing compared to controls, indicating a behavioral measure of reduced anxiety.

Mice treated with MSC and MSC/BDNF had reduction in the degree of striatal atrophy compared to control mice.

We have demonstrated both a behavioral and a structural improvement due to treatment in the YAC128 model.

MSC/BDNF for HD

R6/2 Neurogenesis: 2014-0825 Efficacy study

MSC/BDNF for HD

0

2

4

6

8

10

12

14

16

18

Tg + MSC BDNFMOI 10

Tg + Normosol Tg + MSC WT + Normosol

Aver

age

Fluo

resc

ent I

nten

sity

Doublecortin

* * #

* = Significant to WT, # = Significant to tg + Normosol

Transplantation of MSC with and without BDNF significantly increases neurogenesis activity in the subventricular zone.

Pre-clinical Summary: R6/2 (CAG 120) model

Mice treated with MSC or MSC/BDNF have a significant increase in neurogenesis-like activity in the subventricular zone compared to controls.

These data suggest that MSC/BDNF could work through mechanisms of stimulating endogenous neurogenesis.

Striatal implantation of MSC/BDNF increased the mean lifespan of the R6/2 (CAG 120) mice.

Increasing neurogenesis and striatal neuron survival is a key goal of the planned future clinical trial, HD-CELL.

MSC/BDNF for HD

Pre-clinical Summary

Taken together our results demonstrate that MSC/BDNF reduced anxiety, slowed down or prevented striatal atrophy, and increased the lifespan when using two different transgenic mouse models of HD.

This recovery may be due to the stimulation and

maturation of endogenous neurogenesis promoted by the MSC and enhanced by BDNF.

MSC/BDNF for HD

Clinical Trials

PRE-CELL: We have enrolled 30 patients with early-stage HD. We are collecting clinical data (neurological and psychiatric exams, functional abilities, cognitive evaluation, volumetric brain MRI, and exploratory serum and CSF biomarker studies) with assessments every 6 months. We are determining the rate of change in each parameter for every subject in order to enhance safety and permit exploratory measures of clinical efficacy and biomarkers in the planned Phase 1 trial. HD-CELL: We propose to enroll eligible PRE-CELL subjects who have completed at least one year of longitudinal assessments into HD-CELL. This will be an open-label Phase I dose-escalation trial, and all subjects to be treated will receive bilateral intrastriatal implantation of MSC/BDNF. We plan to enroll 3 dosing groups with 5-7 subjects per cohort.

MSC/BDNF for HD

PRE-CELL Study

Prospective, longitudinal observational study

Primary objective: To establish the rate of change in clinical, imaging and biomarker measures in subjects

Study approved by UC Davis IRB in July 2013, with first subject enrolled in September 2013

Bioethics substudy of subjects and care partners added 2015

MSC/BDNF for HD

ClinicalTrials.gov Identifier: NCT01937923

PRE-CELL Inclusion Criteria

1. Men or women age 18 and older, English speaking, able to give informed consent and comply with study procedures.

2. HD diagnosis confirmed with genetic testing.

3. Early stage HD with Total Functional Capacity (TFC) score of 9-13.

4. Clinically definite signs of HD.

5. Must have a caregiver or informant able to give feedback about the participant and willing to report observations about subject on standardized forms.

6. Subjects of child bearing potential must agree to adequate birth control measures.

MSC/BDNF for HD

Please see http://clinicaltrials.gov/show/NCT01937923

Recruitment and Enrollment

MSC/BDNF for HD

PRE-CELL Recruitment and Enrollment (June 2015)

Screened Enrolled Excluded Pending enrollment

Scheduled for screening

41 31 9 1 0

Number of subjects completing scheduled visits

Screened Baseline V01 (6 mo)

V02 (12 mo)

V03 (18 mo)

41 31 25 17 5

PRE-CELL enrollment will end June 2015

PRE-CELL Interim Results

MSC/BDNF for HD

Rate of change in clinical measures, including functional abilities, independence, motor exam, psychiatric symptoms and cognition

Rate of change in MRI scan measures

Rate of change in serum and CSF BDNF and mutant huntingtin protein levels

PRE-CELL Interim Results: estimated trajectories

MSC/BDNF for HD

Total Functional Capacity Score

Total Problem Behavior Assessment Score Total Motor Score

Independence Score

Cognitive Assessments

MSC/BDNF for HD

Sarah Farias, PhD Associate Professor of Neurology, UC Davis

Julie Stout, PhD

Professor, School of Psychological Sciences Monash University

Structural MRI Analysis

MSC/BDNF for HD

Charles DeCarli, MD Professor, Department of Neurology

Director, IdEA Lab at UC Davis Co-Clinical PI

DeCarli IDeA Lab, UC Davis

MSC/BDNF for HD

Volumetric MRI Brain Analysis

Volumetric analysis showing areas of reduced striatal volume in PRE-CELL subjects (areas in blue)

Volumetric imaging analysis showing change in brain volumes at 6 months

MSC/BDNF for HD

PRE-CELL Biomarkers

Steven Hersch, MD, PhD Professor of Neurology Harvard Medical School

BDNF Mutant Huntingtin Protein

MSC/BDNF for HD

Ethical considerations regarding a first-in-human stem cell gene therapy trial for Huntington’s disease

Kyle Fink, PhD Alexandra Duffy, DO Vicki Wheelock, MD Mark Yarborough, PhD University of California, Davis

MSC/BDNF for HD

HD-CELL: Proposed Phase 1 safety and tolerability trial of MSC/BDNF neurosurgically implanted into striatum using techniques similar to deep brain stimulator implantation

WOC Lopez et al. Stereotactic planning software for human neurotransplantation. Restor Neurol and Neurosci 2014;31:579-595. 2014.

MSC/BDNF for HD

Treatment Cohorts Low dose MSC/BDNF: 5 x 106 cells per striatum

Medium dose MSC/BDNF: 10 x 106 cells per striatum

High dose MSC/BDNF: 20 x 106 cells per striatum

Low dose MSC/BDNF

Medium dose MSC/BDNF

High dose MSC/BDNF

DSMB Pause

DSMB Pause

HD-CELL Schedule of Activities MSC/BDNF for HD

Screening+ Pre-op

Surgery within 30 d

V1 - 4 mo 1-2

V5 3 mo

V6 6 mo

V7 9 mo

V8 12 mo

15-24 mo

Informed consent X

Inclusion / exclusion X X X X X X X X

General exam X X X X X X X

Neuro exam X X X X X X X X

UHDRS X X X X X X X

Safety labs X X X X X X X X

Cognitive battery X X X X X X X

Mood / behavior X X X X X X X

Functional / QOL / CGI X X X X X X

MRI brain scan X X X X X X X X

Biomarkers X X X X X X X

Lumbar puncture X X X X X

Adverse events X X X X X X X X

Interventional Magnetic Resonance Imaging- Guided Cell Transplantation into the Brain with Radially Branched Deployment

MSC/BDNF for HD

a iMRI-guided RBD b Standard stereotactic targeting of a straight cannula

Regulatory Milestones Progress

MSC/BDNF for HD

FDA Pre-preIND 2013

CIRM Clinical Development

Advisory Panel 2014

NIH Recombinant DNA Advisory

Committee June 2015

FDA pre-IND July 2015

FDA IND application Fall 2015

Thank you HD patients and families!

MSC/BDNF for HD

Source: Katie Jackson, Help4HD

Patient Advocate

Power

Patients

Education

Science

Regulatory Industry

Clinic

Community

MSC/BDNF for HD